College of Paramedics The Exchange Express Park Bristol Road Bridgwater TA6 4RR Improving Patients’ Access to Medicines: A Guide to Implementing Paramedic Prescribing within the NHS in the UK. reference COP-IP003 issuing function Chief Executives Office / Medicines & Prescribing Project Lead date of issue February 2018 version V1.00
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College of Paramedics The Exchange Express Park Bristol Road
Bridgwater TA6 4RR
Improving Patients’ Access to Medicines: A Guide to Implementing Paramedic Prescribing within the NHS in the UK.
reference COP-IP003
issuing function Chief Executives Office / Medicines & Prescribing Project Lead
date of issue February 2018 version V1.00
A Guide to Implementing Paramedic Prescribing within the NHS in the UK. COP-IP003 – Feb18 v1.00
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Improving Patients’ Access to Medicines: A Guide to Implementing Paramedic Prescribing within the NHS in the UK.
Conflicts of interest ................................................................................................................................... 12
Funding from other sources ..................................................................................................................... 12
Training and preparation for independent prescribing .............................................................................. 13
Training programmes for independent prescribing ................................................................................... 13
Supervising/Designated Medical Practitioner (DMP) ................................................................................ 14
‘Buddying’ schemes during training .......................................................................................................... 15
Continuing Professional Development ..................................................................................................... 15
‘Buddying’/mentor post - qualification ....................................................................................................... 15
Prescribing medicines under independent prescribing arrangements ...................................................... 16
Prescribing within competence ................................................................................................................. 16
Prescribing for self, family and friends...................................................................................................... 20
Gifts and benefits ..................................................................................................................................... 20
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Guidance on Controlled Drugs ................................................................................................................. 21
Patient records: Access and updating ...................................................................................................... 21
Adverse Drug Reaction Reporting ............................................................................................................ 22
Role of the National Reporting and Learning System............................................................................... 23
Legal and Clinical Liability ........................................................................................................................ 24
Liability of prescriber/professional indemnity ............................................................................................ 24
Liability of employer.................................................................................................................................. 24
Dispensing of prescribed items ................................................................................................................ 25
Dispensing Doctors in primary care.......................................................................................................... 25
Simultaneous prescribing and dispensing or prescribing and administration of a medicine ..................... 25
Verification of prescribing status .............................................................................................................. 26
Role of the pharmacist on verification of prescribing status ..................................................................... 26
Role of the Prescription Pricing Division of the NHS Business Services Authority ................................... 27
Dispensing by appliance contractors ........................................................................................................ 27
Annex A: Notification of prescriber details to the Prescription Pricing Division of the NHS Business Services Authority .................................................................................................................................... 29
Annex B – Prescription Forms- completion .............................................................................................. 30
Annex C: Security and safe handling of FP10 prescription forms ............................................................ 34
Annex D – Good Practice Example of Non-medical Prescribing Clinical Governance Frameworks ........ 36
Annex E – Controlled Drugs ..................................................................................................................... 43
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Document Control
This document has been adapted for the NHS England Allied Health Professions
Medicines Project by the College of Paramedics and is based on the original document
published by the Department of Health in 2006 which supports Nurse and Pharmacist
independent prescribing, with their consent. References to versions and authors from
here on should be viewed in consideration of the original document.
Version Control Comments Authors
Development of draft
versions
Initial development of adapted version of
2006 document to be specific and relevant
to paramedic profession
Dianne Hogg, Shelagh
Morris, Andy Collen,
Gerry Egan, Barry Hunt
V0.01 Completion of draft Dianne Hogg, Shelagh
Morris, Andy Collen,
Gerry Egan, Barry Hunt
V0.02-0.05 Ongoing development of document,
including revisions to assessment matrix
Andy Collen
V0.06 Review of draft Andy Collen, Barry Hunt,
Helen Marriot, Dianne
Hogg
V0.07 First draft for submission for approval Andy Collen
V0.08 Final draft Andy Collen
Developed by the College of Paramedics on behalf of the AHP Medicines Project, NHS England June 2017 College of Paramedics The Exchange Express Park Bristol Road Bridgwater TA6 4RR Telephone: 01278 420014 Email: [email protected] Website: www.collegeofparamedics.co.uk
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Introduction
This guide sets out the administrative and procedural steps needed to enable advanced
paramedics in the UK to act as independent and supplementary prescribers. It provides
information and advice on good practice in the implementation of advanced paramedic
independent and supplementary prescribing. It is adapted from the Department of Health
guidance 20061 to reflect current best practice by other professions in implementing
prescribing2
Scope of this guidance and impact of devolution
1. This guide sets out the steps to implement independent prescribing in the UK.
Medicines legislation permits the introduction of independent prescribing for
paramedics across the UK, but it is for the devolved administrations in Scotland,
Wales and Northern Ireland to decide whether and how it is implemented for the NHS
in their countries.
2. This guide has been produced to help promote safe and effective prescribing by
paramedic prescribers and is applicable to both the NHS and the independent and
voluntary sectors.
3. NHS England is tasked with creating the NHS of the future that will work
collaboratively across all sectors, with social care and commissioners and with
patients and carers. The Government’s mandate for NHS England3 and the Next
Steps4 expect 7-day availability of services, movement of some services from
secondary to primary care, reduction of patients attending A&E/being admitted to
hospital when it is not the best place for their treatment, improvements in the care of
patients with mental health problems and provision of seamless, ‘joined up’ care close
to patients homes- which may be care homes. New care models are required to
deliver many of these improvements which include an increase in the number of
health professionals who can prescribe, supply or administer medicines to patients.
4. The guidance is applicable to paramedic prescribing in all settings; where there are
setting-specific requirements or information this is indicated in the document. It is
1 Department of Health (2006) Improving Patients’ Access to Medicines: A Guide to Implementing Nurse and Pharmacist Independent Prescribing within the NHS in England Click Here
2 Whenever prescribing is referred to in this document, this refers to independent and supplementary prescribing
3 Department of Health (2017) The Government’s mandate to NHS England for 2017-18 Click Here
4 NHS England (2017) Next steps on the NHS Five Year Forward View Click Here
diagnostic and therapeutic radiographers, dietitians, podiatrists and optometrists) can
5 Within medicines legislation the term used is ‘appropriate practitioner’
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prescribe in partnership with a doctor (or dentist). Supplementary prescribers are able
to prescribe any medicine, including controlled drugs and unlicensed medicines that
are listed in an agreed clinical management plan. All supplementary prescribers may
prescribe for any medical condition, provided that they do so under the terms of a
patient-specific clinical management plan (CMP) agreed with a doctor. The CMP will
be drawn up, with the patient’s agreement, following diagnosis of the patient.
Supplementary prescribing may still be the most appropriate mechanism for
prescribing, for instance where an independent prescriber is newly annotated as a
prescriber or where a team approach to prescribing is clearly appropriate, or where a
patient’s CMP includes certain medicines which the prescriber cannot prescribe
independently (for example some controlled drugs).
11. Non-medical health professionals who are legally able to train to become independent
prescribers will also be assessed as supplementary prescribers and their professional
registration will be annotated as such6.
Legal basis of independent prescribing by advanced paramedics
12. The initial legal basis for the introduction of nurse prescribing was provided by the
following regulations:
• The Medicinal Products: Prescription by Nurses, etc. Act 1992 [which amended
the National Health Service Act 1977 (section 41) and the Medicines Act 1968
(section 58)];
• The Medicinal Products: Prescription by Nurses, etc. Act 1992: (Commencement
No 1) Order 1994.
13. Subsequently, section 63 of the Health and Social Care Act 2001 enabled the
Government to extend prescribing responsibilities to other health professions,
including pharmacists. It also enabled the introduction of new types of prescriber,
including the concept of a supplementary prescriber.
14. The Medicines and Human Use (Prescribing) (Miscellaneous Amendments) Order of
May 2006 and associated medicines regulations, and subsequently the Human
Medicines Regulations 2012 and associated amendments enable specific non-medical
health professions to undertake independent prescribing responsibilities.
6 Please refer to “Practice Guidance for Paramedic Supplementary and Independent Prescribers” available via the College of Paramedics web site Click Here
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Aims of independent prescribing
15. It is government policy to extend prescribing responsibilities to non-medical
professions to: -
• improve patient care without compromising patient safety;
• make it easier for patients to get the medicines they need;
• increase patient choice in accessing medicines;
• make better use of the skills of health professionals;
• contribute to the introduction of more flexible team working across the NHS.
• enable patients to be seen and treated in the most appropriate setting by an
appropriately skilled health professional.
• Support medicines optimisation
• Increase capacity to respond to changing demand on services
16. Organisations should develop their strategic plan for the use of non-medical
prescribing to include prescribing by advanced paramedics. Typically, this would
involve senior managers and clinicians (doctors, paramedics, pharmacists) and the
drugs and therapeutics committee (or equivalent medicines governance and
optimisation committee). The plan should be approved at Board level and would, for
example:
• recognise the benefits to patients of non-medical prescribing;
• identify an initial range of clinical areas where patients could benefit;
• identify a way to support and sustain the transition of staff to prescribing roles
and the services they currently provide;
• develop a communications plan aimed at informing both patients and all clinical
and managerial staff;
• include timescales for implementation;
• identify a lead director to be responsible for implementation.
NHS care settings in which paramedic prescribing could apply
17. Increasingly, paramedics are working in a wider range of multidisciplinary settings,
including; GP practices and primary care, community services, secondary care
including critical care units, out of hours, urgent and emergency care services and
within integrated workforce models. Paramedics are employed by or contracted to
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emergency and urgent care departments, primary care settings such as GP practices
and other services.
18. Paramedic prescribers must adhere to the clinical governance arrangements put in
place by the organisation for all non-medical prescribers as described in this
document.
19. Prescribing in primary care settings such as GP practices, community clinics and
patients’ homes usually makes use of FP10 prescription forms. Therefore, this
document includes guidance on handling FP10 forms securely (see Annex D).
Implementation strategy
Which paramedics can act as prescribers?
20. Paramedics must be practising at an advanced level of practice, as defined by Health
Education England in collaboration with NHS England and the allied healthcare
professionals’ professional bodies. Advanced practice is defined as:
“Advanced clinical practitioners (ACPs) come from a range of professional backgrounds such
as nursing, pharmacy, paramedics and occupational therapy. They are healthcare
professionals educated to master’s level in Advanced Clinical Practice and have developed
the skills and knowledge to allow them to take on expanded roles and scope of practice
caring for patients.”7
Advanced Clinical Practice is delivered by experienced registered healthcare practitioners. It
is a level of practice characterised by a high level of autonomy and complex decision-making.
This is underpinned by a master’s level award or equivalent that encompasses the four pillars
of clinical practice, management and leadership, education and research, with demonstration
of core and area specific clinical competence.
Advanced Clinical Practice embodies the ability to manage complete clinical care in
partnership with patients/carers. It includes the analysis and synthesis of complex problems
across a range of settings, enabling innovative solutions to enhance patient experience and
improve outcomes.8
21. A paramedic prescriber must have their name held on the Health and Care
Professions Council (HCPC) professional register, with an annotation signifying that
7 Health Education England (2016) Advanced Clinical Practice Click Here 8 Health Education England (2017) Definition of Advanced Clinical Practice Click Here
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the paramedic has successfully completed an approved programme of preparation
and training for paramedic independent and supplementary prescribing.
Selection of advanced paramedics to train to become prescribers.
22. The selection of paramedics who will be trained as prescribers is a matter for
employing organisations who are best placed to assess local service and patient
needs. Potential prescribers and organisations/managers wishing to implement
paramedic prescribing should complete the checklist in annex F.
23. The entry requirements for HCPC registrants are listed in the following table (Outline
Curriculum Framework 20179):
a) Be registered with the HCPC in one of the relevant Allied Health Professions.
AND
b) Be professionally practising in an environment where there is an identified need for the individual to regularly use independent prescribing (paramedics)
AND
c) Be able to demonstrate support from their employer/sponsor* including confirmation that the entrant will have appropriate supervised practice in the clinical area in which they are expected to prescribe.
AND
d) Be able to demonstrate medicines and clinical governance arrangements are in place to support safe and effective supplementary and/or independent prescribing
AND
e) Have an approved medical practitioner, normally recognised by the employer/commissioning organisation as having:
I) experience in the relevant field of practice,
II) training and experience in the supervision, support and assessment of trainees and
III) has agreed to;
- Provide the student with opportunities to develop competences in prescribing
- Supervise, support and assess the student during their clinical placement.
AND
f) Have normally at least 3 years relevant post-qualification experience in the clinical area in which they will be prescribing.
AND
g) Be working at an advanced practitioner or equivalent level.
AND
9 Allied Health Professions Federation (2017) Outline Curriculum Framework for Prescribers Click Here
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h) Be able to demonstrate how they reflect on their own performance and take responsibility for their own Continuing Professional Development (CPD) including development of networks for support, reflection and learning.
AND
i) In England and Wales, provide evidence of a Disclosure and Barring Service (DBS) or AccessNI check within the last three years or, in Scotland, be a current member of the Protection of Vulnerable Groups (PVG) scheme.
*If self-employed, must be able to demonstrate an identified need for prescribing and that all appropriate governance arrangements are in place
24. The three key principles that should be used to prioritise potential applicants are:
• to maximise patient safety;
• To provide maximum benefit to patients and the NHS in terms of quicker and
more efficient access to medicines for patients and to support medicines
optimisation/streamlining clinical pathways;
• to make better use of the professional’s skills to support service transformation.
The individual practitioners must also understand and accept the higher level of
clinical responsibility and accountability associated with prescribing.
25. NHS organisations may find it helpful to work together locally to agree priorities for
access to prescribing courses in alignment with local priorities and in collaboration
with Local Workforce Advisory Boards and Sustainability and Transformation
Partnerships.
Commissioning services
26. Advanced Paramedic prescribing will give providers of care and all who commission
services the opportunity to transform service delivery. A wider range of professionals
who can act as prescribers provides a range of skills and expertise from which to
draw to meet patient needs. Using paramedic prescribers can, amongst other things,
help to:
• fill geographical or skills gaps in services;
• promote care closer to home
• minimise delays to treatment
• meet the needs of patient groups who find it difficult to access services, e.g.
housebound people;
• reduce avoidable admissions
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Funding for paramedic prescribing training courses
27. In some regions, funding for education programmes is now devolved to NHS
organisations, in others the funding is managed by Health Education England. It is for
NHS organisations to agree how this funding is best used to meet the needs of their
client group.
Non-NHS staff
28. Advanced Paramedics employed by non-NHS organisations, and who provide the
majority of their clinical services to NHS patients (e.g. out-of-hours provider) may
have their training funded. This may need to be considered with commissioners.
Conflicts of interest
29. In nominating for training any paramedics whose posts are directly or indirectly
funded by pharmaceutical and other companies, employers should be aware of, and
take necessary steps to resolve, any conflicts of interests that may subsequently arise
in the paramedic’s practice.
30. Practice guidance 42 in the Practice Guidance for Paramedic Supplementary and
Independent Prescribers document written by the College of Paramedics states the
requirements of the paramedic prescriber where there are conflicts of interest.
31. HCPC registrants should make patients aware of that interest and must ensure
independence from influence when prescribing and maintain a register of interests
which may be produced on request. The register may be kept by the individual or
completed through organisational corporate governance mechanisms.
32. NHS bodies should bear in mind issues of potential conflict of interest when they are
considering commercial sponsorship of events aimed at prescribers.
Funding from other sources
33. If it so wishes, an NHS organisation or a private organisation may also pay for the
training of paramedics through other sources of funding. Individual paramedics may
choose to fund themselves; this is an arrangement with the university of their choice
but they must still meet all the entry requirements for the course (refer to Annex F).
Caution should be taken to avoid creating a conflict of interest in relation to sources
of funding.
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Training and preparation for independent prescribing
Training programmes for independent prescribing
34. The Health and Care Professions Council (HCPC) has set out standards in respect of
prescribing training for paramedics, and will only validate new recordable courses
against these (see HCPC website). The Outline Curriculum Framework (OCF),
hosted by the Allied Health Professions Federation defines the entry criteria and
specific curriculum for all allied health professionals legally able to prescribe. Only
successful completion of programmes approved by the HCPC will lead to annotation
on the HCPC register as a paramedic prescriber. The programme must have been
approved for paramedics before a member of that profession may enter the
programme. It is important to note that not all programmes offer access to all the
prescribing professions. The HCPC offers information about the programmes they
have approved on their website; with contact details for the relevant university for
more specific information.
35. Health Education England has some level of influence over the detail of the
curriculum for prescribing training (as commissioner of the course). It is expected that
course commissioners and validators approve only those courses that demonstrate
content that is consistent with published guidance and that the learning outcomes of
the curricula are to be achieved.
36. Approved education programmes leading to annotation on the relevant professional
register as an independent and supplementary prescriber must be a specific
programme of preparation at a minimum of degree level (level six), usually Master’s
(level 7). The programme comprises a minimum of 26 days at a Higher Education
Institution (HEI) plus 12 days 'learning in practice', during which a supervising
designated medical practitioner will provide the student with supervision, support and
opportunities to develop competence in prescribing practice. The programme of
training and preparation may be spread over a period of time defined in the Outline
Curriculum Framework (AHPF, 2018). The student will also need to undertake an
element of self-directed learning. For distance learning programmes, there must be a
minimum of 8 face-to-face taught days (excluding assessment) plus 10 ten days
protected learning time. In exceptional circumstances where this is not practically
possible, video-conferencing in which interaction between all participants is possible
will be acceptable. Attendees on the multidisciplinary training programmes will be
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already expert practitioners working at advanced clinical practice level and meeting
the entry requirements as detailed in paragraph 23.
37. The training programmes include an assessment of theory and practice that must be
passed before the practitioner’s entry on the HCPC register is annotated, to indicate
that he/she has successfully completed a prescribing training programme.
38. Individual higher education institutions, where appropriate, may use approved prior
learning (APL) or exemptions, to give credit for previous learning.
39. In addition to the time spent on the formal programme, it is important that employers
of paramedics undertaking the programme should recognise the demands of private
study and provide support where necessary. Employers may also consider providing
mentoring opportunities for these paramedics (see below).
Supervising/Designated Medical Practitioner (DMP)
40. The period of learning in practice will be directed by a DMP, who will also be
responsible for assessing whether the learning outcomes have been met and
whether the trainee has acquired certain competencies, as identified in the
Competency framework for all prescribers10.
41. The Designated Medical Practitioner (DMP) has a critical and highly responsible role
in educating and assessing the non-medical prescriber and assuring competence in
prescribing.
42. Before taking on the role of DMP, the doctor and the HEI should consider the
implications of undertaking this role safely and effectively. It is then important that the
DMP and the HEI running the prescribing programme should work closely together.
43. ‘Training non-medical prescribers in practice – A guide to help doctors prepare for
and carry out the role of designated medical practitioner’ published by the National
Prescribing Centre in 2005 should help to inform the selection of Designated Medical
Practitioners and supports DMPs in undertaking this role.
44. Training new prescribers will undoubtedly take up some time. The approach to
teaching and learning should be developed on an individual basis, so it is difficult to
predict how much time this will involve.
10 Royal Pharmaceutical Society (2016) A Competency Framework for all Prescribers Click Here
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or pharmacist and is a sensible way of enhancing continuing professional
development.
50. Supplementary prescribing is also a useful mechanism to enable new non-medical
prescribers to develop their expertise and confidence in prescribing.
Prescribing medicines under independent prescribing arrangements
51. Paramedics who have successfully completed an independent prescribing course may
prescribe any licensed medicine, (i.e. products with a valid marketing authorisation
(licence) in the UK), and any licensed medicine used outside of the marketing
authorisation (off-license / off-label), for any medical condition within their clinical
competence, scope of practice and level of experience. Subject to legislative change,
they may be permitted to prescribe certain controlled drugs to be administered via
specified routes. This list is available in the Drug Tariff and the BNF.
Prescribing within competence
52. All paramedic prescribers must work within their own level of professional
competence and expertise, and must seek advice and make appropriate referrals to
other professionals with different expertise. Paramedics are accountable for their own
actions, and must be aware of the limits of their skills, knowledge and competence.
Paramedic prescribers must act within the HCPC standards of professional conduct,
performance and ethics13, and the HCPC standards for prescribing14.
Controlled Drugs
53. Subject to changes to the Misuse of Drugs Act, paramedic independent prescribers
will be able to prescribe from the list of controlled drugs specified in annex E.
Prescribing licensed medicines for unlicensed uses (‘off-label’ or ‘off-licence’) 54. Paramedic prescribers may prescribe medicines independently for uses outside their
licensed indications / UK marketing authorisation (known as ‘off-licence’ or ‘off-label’).
They must however, accept professional, clinical and legal responsibility for that
prescribing, and should only prescribe ‘off-label’ where it is accepted clinical practice.
A local policy for the use of medicines ‘off-label’ should be approved through
mechanisms such as drug and therapeutic committees or the equivalent. The
13 Health and Care Professions Council (2016) Standards of conduct, performance and ethics Click Here
14 Health and Care Professions Council (2013) Standards for Prescribing Click Here
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their practice, as for any other, and must act at all times in accordance with the
HCPC Standards of Conduct, Performance and Ethics22
Dispensing of prescribed items
Dispensing Doctors in primary care
90. Where a GP practice is a dispensing practice, prescriptions from independent
prescribers can be dispensed by the practice but only for the patients of that practice.
Dispensing doctors cannot dispense prescriptions written by paramedic prescribers
for patients of other practices.
91. Reimbursement for prescriptions written by paramedic prescribers can be claimed by
dispensing doctors; payment for the prescriptions submitted will be made to the
senior partner.
Simultaneous prescribing and dispensing or prescribing and administration of a medicine
92. There should, other than in exceptional circumstances, be separation of prescribing
and dispensing roles, in keeping with the principles of safety, clinical and corporate
governance. The “Practice Guidance for Paramedic Independent and Supplementary
Prescribers”23, published by the College of Paramedics states that paramedics should
ensure that there is separation of prescribing and dispensing wherever possible. In
exceptional circumstances, where a paramedic is both prescribing and dispensing a
patient’s medication, a second suitably competent person should be involved in the
checking process.
93. In such exceptional circumstances, prescribing and dispensing can be carried out by
the same individual, provided that:
• clear accountability arrangements are in place to ensure patient safety and
probity, and;
• there are audit and clinical governance arrangements in place, which can track
prescribing and dispensing by paramedic prescribers.
22 Health and Care Professions Council (2016) Standards of conduct, performance and ethics Click Here 23 College of Paramedic (2018) College Web Site Click Here
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Prescribing by hospital-based paramedic prescribers
10. Paramedic prescribers prescribing for hospital inpatients or outpatients may use the
following methods to prescribe:
• Hospital in-patient prescription form or sheet - to be used for inpatients and
discharge supplies only. A prescription charge is not levied for inpatients.
• Internal hospital prescription form – to be used for outpatients but only in cases
where the hospital pharmacy will dispense the prescription. A prescription charge
may be payable, unless the patient is exempt from prescription charges. (please
note: internal hospital forms cannot be accepted for dispensing by community
pharmacies).
• Electronic prescription and administration systems- many hospitals are
implementing these systems across all services provided by the organisation
where medicines are prescribed and administered. Local support and
implementation teams will enable the paramedic prescriber to be registered with
the system and enabled to prescribe.
• FP10 prescription forms, where the medicine will be prescribed by a hospital
prescriber and dispensed in a community pharmacy. These are mainly used in
circumstances where the service is delivered away from the hospital site and
therefore the pharmacy (please note: the prescriber’s employer should establish a local policy on the use of prescription forms in these circumstances.). These
prescriptions are printed with previously agreed service-specific prescribing
account details, not individual prescriber details. Prescribing (EPACT) data is
available from the NHSBSA but is displayed at service level only. There is
currently no requirement to notify the NHSBSA of details of hospital-based
paramedic prescribers, or changes to their details. If paramedic prescribers need
to use these prescriptions, they must write their prescribing designation on each
prescription as: PARAMEDIC PRESCRIBER and the prescriber’s HCPC
registration number.
Non-NHS Employees
12. A non-NHS paramedic prescriber cannot issue an FP10 type prescription, i.e. one
which will be dispensed in a NHS community pharmacy, unless the organisation they
work for is commissioned to provide an NHS service and has an arrangement which
allows the non-NHS organisation to use NHS community pharmacy dispensing
services. The NHS commissioner should organise the supply of FP10 type
prescription forms (and obtain the prescribing code(s) to be used) for the non-NHS
organisation, if this is appropriate.
How to complete a prescription form
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13. Detailed, up to date advice on prescription writing is contained in the British National
Formulary (BNF). Paramedic prescribers must refer to the current edition of the BNF.
14. Details required on the front of the prescription form (to be entered by writing clearly
and legibly using an indelible pen - preferably black or, where possible, by printing
using a computer prescribing system) are as follows:
• the patient's title, forename, surname and address (including postcode) and if
available the patient’s NHS number • patient’s age and date of birth (must be printed by computer prescribing systems;
for hand written prescriptions - enter if known e.g. from patient’s notes - BUT it is a
legal requirement to write the patient’s age on the prescription when prescribing Prescription Only Medicines for a child under twelve years of age)
• for prescribing in primary care settings the prescription should contain the name of
the prescribed item, formulation, strength (if any) dosage and frequency, and
quantity to be dispensed. If a medicine is to be taken as required, a minimum dose
interval should be specified. The name should reflect the description in the BNF,
should be written clearly and not abbreviated
• the quantity prescribed should be appropriate to the patient's treatment needs,
bearing in mind the need to avoid waste. Some medicines are only available in
patient packs (or multiples thereof)26 27 and special containers28 and the quantity
contained should be prescribed, provided this is clinically and economically
appropriate. This also ensures that an authorised patient information leaflet is
supplied with the medicine
• the quantity should be specified for solid preparations as number of dose-units
(number of tablets, capsules, lozenges, patches etc.), for liquid measures in
millilitres (mL or ml) or litres, for topical preparations by mass (grams, g) or volume
(millilitres, mL or ml). Terms such as “1 Pack” or “1 OP” should not be used
• alternatively, for preparations to be given at a fixed dose and interval, the duration(s)
of treatment can be given in place of quantity to be dispensed
• the unnecessary use of decimal points should be avoided e.g. 3mg not 3.0mg.
Quantities of 1 gram should be written as 1g, less than 1 gram should be written in
milligrams e.g. 500mg not 0.5g. Likewise, quantities less than 1mg should be
26 A patient pack is a manufacturer's pack approved by the Licensing Authority which has a label and leaflet and contains an amount of medicine such that the pack is capable of being given whole to a patient to meet all or part of a treatment course. For some medicines, special packs containing smaller quantities will be available for starter/titration/trial purposes. 27 In the BNF, pack size is indicated as in this example "Net price 60-tab pack=£2.25". Wherever no pack size is indicated, as in "Net price 20=9p, the quantity is shown for price comparison purposes only. 28 A special container is a pack from which it is not practicable to dispense an exact quantity, or a pack with an integral means of application. This currently includes sterile preparations, effervescent or hygroscopic products, liquid preparations which are intended to be added to bath water, coal tar preparations, viscous preparations and all products packaged in casters, tubes, dropper bottles, aerosols, puffers, roll-on packs, sachets, sprays, shakers, squeeze packs.
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written in micrograms e.g. 100 micrograms not 0.1mg. Use of the decimal point is
acceptable to express a range e.g. 0.5-1g. ‘Micrograms’ and ‘nanograms’ should
not be abbreviated. Similarly, ‘units’ should not be abbreviated. See the BNF for the accepted list of abbreviations
• any warnings that will not be printed automatically onto the label for the medicine by
the dispensing pharmacist (see the BNF for the list of warnings) must be written
onto the prescription
• computer-issued prescriptions must contain the same patient-specific data as
described above. The prescription must be printed in English without abbreviation,
the dose in numbers, the frequency in words and the quantity in numbers in
brackets e.g. 40mg four times daily (112) or by indicating length of treatment
required. The name of the medicine must come from a dictionary within the
computer’s memory. The BNF gives advice if the medicine required is not listed in
the dictionary
• in hospitals, prescriptions for inpatients should contain the name of the prescribed
item, formulation, strength (if any), dosage and frequency. Where a defined length
of treatment is required, this should be stated
• for outpatients and discharge prescriptions, the requirements are the same as
those for primary care settings, whilst recognising local policies for example on the
length of treatment provided for outpatients and patients who are being discharged
• the names of medicines should be written clearly following BNF descriptions
• Paramedics are recommended to prescribe generically, except where this
would not be clinically appropriate or where there is no approved generic name
– see the BNF, the Drug Tariff and/or the marketing authorisation (summary of
product characteristics) of the medicine. Names of medicines and generic titles should
not be abbreviated. Exceptions to this rule are for the prescribing of some dressings
and appliances, and of compound or modified release medicines which have no
approved non-proprietary name
• directions for use, which should be in English and not abbreviated
• where there is more than one item on a form, a line should be inserted between
each item for clarity
• unused space in the prescription area of the form should be blocked out with, for
example, a diagonal line (to prevent subsequent fraudulent addition of extra items)
• prescriber’s signature and date and type of prescriber if not already printed
• on hospital prescriptions only: the paramedic prescriber’s name printed or
handwritten in the box provided- to ensure that the dispensing pharmacist is aware
who to contact if they have a query.
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Annex C: Security and safe handling of FP10 prescription forms The security of prescription forms is the responsibility of both the employing organisation
and the prescriber. The most up to date detailed guidance for security of prescription
forms can be found on the NHS Protect section of the NHSBSA website
www.nhsbsa.nhs.uk. The following information is an extract from ‘Security of Prescription
Forms 2015.29 The full document must be referred to when writing organisational policies.
The prescriber’s responsibilities 1. Be aware that blank prescription forms in the wrong hands are like a blank cheque
with an extremely high street value.
2. Prescription form stock in possession of prescribers should always be stored
securely when not in use.
3. Prescribers should keep a record of the serial numbers of prescription forms issued
to them. The first and last serial numbers of pads should be recorded.
4. Prescribers should be encouraged to use prescription forms in number sequence
order to aid tracking of usage, should a potential loss occur
5. To reduce the risk of misuse, blank prescriptions should never be pre-signed.
6. Patients, temporary staff and visitors should never be left alone with prescription
forms or allowed into secure areas where forms are stored.
7. Prescribers on home visits should, before leaving the practice premises, record the
serial numbers of any prescription forms/pads they are carrying. Only a small number
of prescription forms should be taken on home visits – ideally between 6 and 10 – to
minimise the potential loss.
8. Prescribers on home visits/working in the community should take suitable
precautions to prevent the loss or theft of prescription forms. Keep them out of sight
when not in use and do not leave any prescription forms in vehicles overnight.
9. Prescribers using the FP10PCD forms should exercise extra caution as there is
greater potential for misuse of these forms.
10. Blank or signed prescription forms should never be left at patients’ homes, care homes or community pharmacies for GP or locum visits.
11. Personalised forms which are no longer in use should be securely destroyed (e.g. by
shredding) before being put into confidential waste, with appropriate records kept.
12. Spoiled or cancelled prescription forms should be retained for audit purposes.
13. In the event of a loss or theft of prescription form stock, local procedures should be
followed and the practice manager/employer/non-medical prescribing lead, area
team, Controlled Drugs Accountable Officer and the police should be notified as
required. The incident should also be recorded on the organisation’s incident reporting system. NHS Protect should also be notified at
NB All of the above requirements highlight the need for clear channels of
communication, both within and between organisations
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Annex D – Good Practice Example of Non-medical Prescribing Clinical Governance Frameworks Non-Medical Prescribing: An Outline Governance Framework for Local
Organisations
Adapted from document of the same name, written by M Cossey, North and East Yorkshire and
Northern Lincolnshire SHA WDC and incorporating aspects of the Non-medical Prescribing
Clinical Governance Framework written by L Wright and C Orme, Trent Strategic Health
Authority; both first published in DH (2006) Improving Patients’ Access to Medicines.
1. The development of non-medical prescribing (NMP) is a key policy initiative that aims
to maximise benefits to patients and the NHS by:
• providing better access to medicines and
• better, more flexible use of the workforce skills
2. As paramedic prescribing is rolled out nationally it is important that all those involved
understand the responsibilities of individual practitioners, managers and organisations
in ensuring safe and effective implementation and practice of NMP. Ensuring patient
safety is an integral part of all healthcare providers’ clinical governance arrangements.
Key steps for NHS organisations to have in place to ensure the implementation of
clinical governance include:
• Clear lines of responsibility and accountability for overall quality of clinical care
• Development of quality improvement programmes
• Management of risk
• Clear procedures to identify and remedy poor performance.
3. This framework sets out the key elements that organisations and individual
practitioners should have in place or be in the process of addressing, in order to ensure
that the development of NMP is implemented within a mechanism that develops safe
and effective practice. The framework should be read in conjunction with any policies
and procedures that local organisations have in place for implementing NMP or any
general policies related to prescribing and medicines management. It should also be
read in conjunction with any national or professional guidance issued by the HCPC
and the College of Paramedics
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1. Organisational Leadership and Strategy for Non-medical Prescribing (NMP)
Overarching statement: Clear lines of responsibility and accountability exist for all organisations in relation to
the leadership, planning and implementation of NMP
Governance
arrangements
required by
organisations:
a) All organisations have a nominated named lead (or leads) for overseeing the development and implementation of NMP. Where different professional leads are in place co-ordination / networking between these leads is required to ensure consistency of approach to implementation and monitoring. The NMP lead should be linked directly with the Drugs and Therapeutics committee or equivalent. NMP should be linked into organisation prescribing and medicines management arrangements within the organisation where appropriate.
b) Organisations should have in place an integrated policy around the strategic development and implementation of NMP. This should include: named leads for NMP, stakeholder and patient/public awareness initiatives, implementation plans for NMP, advice about training, internal arrangements for monitoring, mechanisms for application and training, processes for obtaining prescription pads, signposting to any relevant policies and procedures, and any other relevant local information.
c) A co-ordinated database or register of all trained non-medical prescribers prescribing in that organisation should be maintained within all organisations. This database records all newly qualified prescribers; those employed by the organisation or another organisation commissioned to provide the prescriber and should note those NMPs who leave the organisation. It should also note the designated status of all NMPs (e.g. community practitioner nurse prescriber, independent/supplementary prescriber, supplementary prescriber) and the profession of the prescriber
d) Systems are in place to inform non-medical prescribing lead in the Trust when new prescribers are employed and prescribers leave.
e) A contact point within the organisation for any queries on the prescribing status of staff. i.e. from dispensing pharmacists
f) Non-medical prescribing is an integrated part of organisational clinical governance arrangements and relevant action plans. Organisations must consider the impact of NMP on other related policies and procedures e.g. medicines-related error reporting.
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Overarching statement: Clear lines of responsibility and accountability exist for all organisations in relation to
the leadership, planning and implementation of NMP
Governance
arrangements
required by
organisations
(cont.):
g) All planned developments for NMP should be linked to strategic service development within the organisation For example: Long term conditions, improved access to medicines and services, practice based commissioning; service modernisation and redesign.
h) Decisions to train individuals as NMPs should be linked to personal development plans and candidates should be assessed for competency related to knowledge and skills in their area of potential prescribing practice. the Competency Framework for all Prescribers is available from the Royal Pharmaceutical Society at https://www.rpharms.com/resources/frameworks/prescribers-competency-framework (Note: it is not intended that individuals are competent to “prescribe” prior to training but organisations should be assured that practitioners have the necessary clinical skills and knowledge in their area of practice which will enable them to prescribe safely and effectively once trained OR that CPD and additional training is planned to ensure these can be met. Organisations should also check that individuals would meet the necessary Higher Educational Institute (HEI) entry requirements).
i) All plans to train NMPs should also include an assessment of: service specification, access to a prescribing budget (or equivalent in acute trusts / secondary care), development of necessary policies or documentation e.g. clinical management plans (CMPs)
j) Links should exist between NHS organisations, HEIs and Health Education England to ensure effective monitoring of applications, funding, and quality of training, monitoring of numbers and professions trained, and attrition rates from modules.
k) Ongoing support and network arrangements are in place for all NMPs including discussion of NMP at annual appraisal and access to relevant CPD. Job descriptions are amended to account for prescribing responsibilities.
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2. Information governance and risk management of NMP
Overarching statement: Clear policies exist or links to existing policies are explicit for all managers and NMPs
in relation to information governance and risk management of NMP.
Governance
arrangements
required by
organisations:
(See also 1c above)
a) All NMPs should be linked to all organisational systems to ensure prescribers are kept informed of relevant clinical, therapeutic and prescribing information e.g. BNF, MHRA alerts, Drug Safety Alerts etc.
b) A risk management plan is in place which will ensure that potential risks associated with extending clinical practice are recognised and minimised
c) NMP practice is monitored through the same routes as medical prescribing (e.g. ePACT data, audit and feedback in primary care, local mechanisms in acute Trusts) and that information is available to practitioners and managers where appropriate, in line with internal arrangements.
d) The parameters of an individual’s prescribing should be agreed between the prescriber, their manager or local professional lead (e.g. the non-medical prescribing lead), and their employer. This is best carried out using a personal formulary approach which is a continuation from that developed during the course of study. The formulary should include the context in which the non-medical prescriber will prescribe the medicine and how the knowledge and competence to prescribe the medicine was achieved and is being maintained/developed.
e) All NMPs are aware of the importance, how to and are encouraged to report adverse drug reactions via the national Yellow Card system
f) All NMPs understand the importance of reporting Serious Untoward Incidents and are aware of the local mechanisms for doing this as well as National Reporting and Learning System (NRLS) reporting.
g) NMP should be aware of and adhere to the organisational policy regarding relationships with the Pharmaceutical Industry
h) All record keeping guidance and protocols/templates for prescribing practice are updated regularly as detailed within PCT/Trust policies e.g. CMPs should be revisited and amended where necessary and at least annually
i) All medical prescribers should be aware of NMPs within the organisation and when and how they may interact with
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Overarching statement: Clear policies exist or links to existing policies are explicit for all managers and NMPs
in relation to information governance and risk management of NMP.
patients to ensure consistency of record keeping and continuity of patient care.
j) Organisations (including GP practices) should keep records of prescription pad numbers linked to prescriber name for tracking any lost or stolen prescriptions, where prescription pads are used
k) Organisations should review their policies related to medico-legal accountability and information made clear to NMPs regarding accountability, vicarious liability and personal indemnity. (Practitioners should also be advised to contact their professional regulatory bodies).
l) The names of prescribers are annotated on their professional register, before they begin to prescribe
3. Audit and Quality Improvement
Overarching statement: Mechanisms should be in place to include NMP in relevant audit. Audit cycles and
review processes should be employed to ensure that the implementation and
development of NMP is progressing in a safe and effective manner that is benefiting
patients and services.
Governance
arrangements
required by
organisations:
a) All review and updating of organisational prescribing and medicines supply policies include an impact assessment of NMP and are revised accordingly.
b) All CMPs used by supplementary prescribers are reviewed (at least annually but more frequently where changes to patient’s treatment plan, policy or evidence dictate) to ensure they are based on sound clinical evidence and are safe and cost effective.
c) All NMP practice should be integral part of prescribing policy audit including adherence to NICE Guidance, other national or local clinical guidelines and any relevant local or national prescribing and medicines management policies.
d) Evidence of tracking and monitoring arrangements should be in place to ensure the continuing competency of NMPs and their access to relevant, appropriate CPD. Systems should be in place to challenge competence issues.
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4. Patient and Public Involvement
Overarching statement: There should be mechanisms in place in organisations to ensure patients and public
are aware of NMP practice and have a say in any related developments or audit of
NMP services.
Governance
arrangements required
by organisations:
a) Patients and the public should be made aware of any developments in NMP which may alter services in order that they can make informed choices and understand what NMP means for them and the delivery of their care.
b) Methods to include patient and public comments in any NMP service review should be standard practice within all organisations
c) Patient / public information should be available in all organisations outlining what NMP is, what it means for patients and any specific services where NMP is being used in that area.
d) Patient / public involvement forums should be briefed about NMP where relevant and appropriate and information provided in a useable format.
5. Responsibilities of Individual NMP practitioners and information resources
Whilst is understood that organisations need to have robust governance arrangements in
place for their NMP staff, individual practitioners have responsibility for ensuring they are
clinically competent for their role, undertake appropriate CPD, practice within the law and
any agreed local policies and abide by the HCPC Standards of Conduct, Performance
and Ethics30
Standards of prescribing are available on the HCPC website31 Guidance for prescribing
practice are available from the College of Paramedics
The Competency Framework for all Prescribers, available from the Royal Pharmaceutical
Society,32 should be used by organisations, managers and individuals to assess
competence to prescribe.
NICE currently purchases an annual supply of the British National Formulary and the
British National Formulary for Children. Access to these resources is also available via
‘Medicines Complete’ and as an ‘app’ for mobile devices such as phones. Not all
30 Health and Care Professions Council (2016) Standards of conduct, performance and ethics Click Here
31 Health and Care Professions Council (2013) Standards for Prescribing Click Here
32 Royal Pharmaceutical Society (2016) A Competency Framework for all Prescribers Click Here
3. Supplementary prescribers can, within their declared competence, prescribe any
controlled drug from schedules 2 – 5 for any medical condition within their declared
competence and by any route of administration that is included in a patient's clinical
management plan and agreed by a doctor with the exception of diamorphine, cocaine
and dipipanone for the treatment of addiction.
4. If it is within the paramedic prescriber’s role and competence to prescribe scheduled and controlled drugs, the prescriber must agree this with the immediate line manager
and inform the Non-medical Prescribing Lead and the Controlled Drugs Accountable
Officer using the personal formulary or competency declaration route They must also
be able to demonstrate:
• Knowledge and understanding of the mode of action and pharmacokinetics of
medicines, how these mechanisms may be altered (e.g. by age, renal
impairment) and how this affects dosage
• Knowledge and understanding of the potential for unwanted effects, (e.g. adverse
drug reactions, dependency, drug interactions, allergy), and how to
avoid/minimise and manage them
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• Appreciation of the misuse potential of drugs
• Application of the principles of evidence-based medicine, and clinical and cost-
effectiveness
• Understanding of the public health issues related to medicines and their use
• Competence in the management of conditions to be treated,
5. In addition to the legal requirements for the prescribing and use of controlled drugs,
knowledge of both local and national protocols for prescribing controlled drugs and
other medicines with the potential for misuse.
6. Some organisations may wish paramedic prescribers to undertake CPD e.g. MHRA
Opioids e-learning programme or other resource prior to prescribing controlled drugs.
7. The prescribing by paramedic prescribers of controlled drugs and other drugs with
the potential for misuse such as hypnotics and anxiolytics will be closely monitored.
8. The Misuse of Drugs Act and Human Medicines Regulations govern the prescribing
of Controlled Drugs. For guidelines on the prescription of Controlled Drugs,
healthcare professionals should refer to:
• College of Paramedics: Practice Guidance for paramedic supplementary and
Independent Prescribers, in particular practice guidance 25
• Organisational controlled drugs policies and procedures
• A guide to good practice in the management of controlled drugs in primary care,
published by the National Prescribing Centre. www.npc.co.uk
• Safer management of controlled drugs: a guide to good practice in Secondary
Care www.dh.gov.uk
• The legal requirements for prescriptions for Schedule 2 and 3 Controlled Drugs
are summarised in the BNF and the GPhC’s publication, ‘Medicines, Ethics and Practice: a guide for Pharmacists’ (subscription only).
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Annex F: Checklist for Potential Prescribers and/or Organisations Introducing Prescribers
The following checklist provides a list of pre-requisite features required in order to move towards prescribing, and provides a link to the associate standards
and legislation which may form part of your Professional Development Plan needed to ensure you meet the minimum criteria (and to maintain this). This
checklist may be used regularly after qualification as an independent prescriber to ensure you still fulfil the requirements necessary to undertake independent
prescribing. You MUST be able to answer YES to all topics before considering non-medical prescribing.
Topic Evidence Self-Assessment Standards and
Guidance Documents Your Evidence
Yes Needs Development No
Your Clinical Role
Your employer provides clinical services which require independent prescribing (do you have a clear prescribing role)
Your role is currently limited by not being able to independently prescribe, or is a requirement of the role you are training for
Your Professional Qualification and Post-registration experience
You are registered with the HCPC and have no sanctions or conditions applied
You have (or are working towards) an advanced practice qualification (typically MSc/other study at Masters level which fulfils the HEE definition of Advanced Practice) and have achieved the award within the last 6 years, or have evidence of continuous practice at that level if achieved to longer than 6 years ago.
HEE - definition of Advanced Practice
You are, and have been, practising in your area of expertise for at least 12 months
You have been qualified and registered for at least 5 years
You have evidence of post-registration study (for example, DipHE or PGDip)
You have a qualification, experience and evidence of competency of diagnostics, physical examination and decision making skills relevant to your area(s) of prescribing practice.
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Topic Evidence Self-Assessment Standards and
Guidance Documents Your Evidence
Yes Needs Development No
Your Organisation
You are employed by an organisation which is providing clinical services, and which has recognised a need for prescribing roles.
Your organisation has access to a pharmacist who is familiar with non-medical prescribing, and a Non-medical Prescribing Lead.
Your organisation has an established non-medical prescribing policy, governance processes, and prescribing budget which meet the minimum best practice standards
Your organisation employs a Medical Director or other Clinician delegated to oversee non-medical prescribing
Your organisation has sufficient access to a Designated Medical Practitioner (DMP) who meets the criteria (NPC, 2005), and who can supervise trainee non-medical prescribers.
Web Link - NPC 2005
Your Prescribing Education
You meet all educational requirements for entering an approved non-medical prescribing programme and you have experience and competence in using medicines legislation for administration, possession and supply of medicines
You have read and understood the Royal Pharmaceutical Society’s competency framework
RPS - A Competency Framework for all Prescribers
You have read and understood the Allied Health Professionals Federation Outline Curriculum Framework for independent and supplementary prescribing
AHPF Outline Curriculum Framework
You have access to funding for non-medical prescribing education, or you are able to self-fund.
You have access to a DMP who can support your prescribing training
Your CPD Plan and Opportunities
You have a detailed professional development plan which includes development as a prescriber. You can demonstrate attendance at relevant events, and a clear plan to take CPD opportunities in the future as a prescriber.
HCPC standards for continuing professional development. HCPC Standards for Prescribing
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Topic Evidence Self-Assessment Standards and
Guidance Documents Your Evidence
Yes Needs Development No
Your Supervision Plan and Opportunities
You are able to identify a suitable non-medical prescribing supervisor (buddy system), and have liaised with your non-medical prescribing lead (if available) to discuss supervision needs.
Your Local Prescribing Network
You are aware of your local prescribing network and have discussed with your non-medical prescribing lead the role and function of this group.
Your Ongoing Role and Career Plans
A clinical role is part of your career plan and you should seek to undertake prescribing as a core aspect of your clinical career for at least 3 years
You understand the implications of ceasing to prescribe as part of your practice within your role.
HCPC - prescribing training
Your Regulator
You understand the guidance issued by your regulator (HCPC)
HCPC Standards for Prescribing
You understand and follow the Standards of Performance, Conduct and Ethics issued by the HCPC
HCPC Standards of Conduct, Performance and Ethics
You understand and follow the Standards of Proficiency for Paramedics issued by the HCPC
HCPC Standards of Proficiency for Paramedics
Your Professional Body’s Practice Guidance
You understand the role of the professional body – the College of Paramedics, and understand its role in relation to practice guidance, indemnity, CPD and professional standards
You have read and understood the Practice Guidance issued by the College of Paramedics
College of Paramedics: Practice Guidance for paramedic supplementary and Independent Prescribers